It is currently unclear whether or not there is any additional benefit in adding antiplatelet therapy (APT) to anticoagulation therapy (ACT) in patients who are at high risk of thromboembolic events (TEs) resulting from AF in terms of a reduction in vascular events, including stroke. Existing guidelines acknowledge an increased risk of bleeding but there is no consensus on the treatment pathway.
A total of 53 publications were included in this review but were not considered to be high quality. There was variation in the population, types and doses of ACT and APT, definitions of outcomes, and length of follow-up between the studies. There was a paucity of directly randomised high-quality RCTs for adequate meta-analysis, whereas non-randomised comparisons were found to have significant confounding factors. Collectively these studies did not add any further insight.
The authors concluded that, “a definitive prospective RCT needs to be undertaken in a population at high risk of atherosclerotic coronary artery and other vascular events in addition to being at high risk of AF-mediated TEs. From the UK context, at the time of writing, any future trial should compare adjusted-dose warfarin [international normalised ratio (INR) 2.0-3.0] plus aspirin (75-325 mg) with adjusted-dose warfarin (INR 2.0-3.0). However, given the emergence of newer anticoagulation agents (dabigatran, rivaroxaban and apixaban) this prioritisation may need to be revisited in the future to reflect current best clinical practice.”